Mentalizing psychiatric training

In their remarkable paper, Castellini et al¹ provide us with not so much a survey but a census of psychiatric trainees in Italy with a remarkable response rate of over 80% compared with a more quotidian comparison group of medical trainees at a similar point of their professional development. The comprehensiveness of their approach permits a tentative conclusion about the average mental state of psychiatric residents—it seems young doctors do not generally go into the mental health specialty to address their own psychological needs; trainee psychiatrists are, on average, less neurotic, notwithstanding above-average childhood adversity. The report also adds to the growing literature that trainees who feel supported and mentally well will perform better in the workplace in the long run,² at least in terms of symptoms of burnout.

The study, being cross-sectional and relying solely on self-report data, inherently restricts the extent to which we can confidently infer causality from the observed associations. However, with the authors' indication that future longitudinal data might be provided, it is worthwhile to cautiously consider the implications of the reported correlations. For this purpose, we shall make the generous assumption that these correlations represent authentic associations and are not skewed by factors like recall bias, social desirability bias or the impact of any unmeasured confounding variables. The correlations, albeit tentative, provide a starting point for deeper investigation into the factors contributing to burnout and the potential avenues for intervention, while fully recognising their limitations we can acknowledge the value they add to the ongoing discourse on mental health and resilience in medical training.

Work-related burnout syndrome, characterised by the triad of emotional exhaustion, cynicism and low sense of professional efficacy³ has been associated with stress-related health problems,⁴ broken personal relationships,⁵ inadequate patient care⁶ and reduced learning capacity.⁷ Medical doctors experience higher rates of burnout syndrome than the general population⁵ likely because a critical factor in the development of burnout is the sustained mismatch between job demands and resources available. Training years, more than any other stage in physicians' career, are characterised by this type of imbalance due to long and irregular work hours⁸ and high levels of responsibility combined with lack of professional experience.⁹ Psychiatry itself adds several very specific stressors such as perceived stigma of this profession, demanding therapeutic relationships, personal threats from violent patients and the risk of patient suicide.¹⁰

The report by Castellini et al importantly extends the research connecting early adversity with an increased susceptibility to burnout.^11-14 Their work offers new insights by elucidating a mediating pathway from childhood adversity to burnout risk in psychiatric and other medical trainees. This pathway involves attachment insecurity and low self-mentalizing, evidenced by inadequate emotion regulation and coping strategies. These factors, in turn, lead to deficient interpersonal skills, which may not sufficiently shield junior doctors from the heightened risk of burnout.

This model presented by Castellini et al is compelling and aligns with the concept that mentalizing—the capacity to understand oneself and others in terms of mental states—is crucial for adaptability and resilience.¹⁵ Their findings suggest that interventions aimed at enhancing mentalizing abilities and interpersonal skills could be beneficial in reducing burnout risk, particularly for those with a history of early adversity.

Although the statistical model they create is clearly robust and offers a model of resilience rich in pragmatic implications, it is also valuable because it presents the human capacity for mentalizing in an appropriate systemic context. They essentially integrate our attachment theory inspired mentalizing approach into a systems framework. They invite us to think about mentalizing in a holistic way, taking an approach to understanding, which highlights the interrelated components of the mentalizing system and explores their interaction over time, particularly from a developmental perspective—not just childhood to adulthood but also throughout the paths trainees can take during residency. There are limitations to most of our statistical models. In life, arrows rarely progress in an orderly manner from left to right. Mentalizing may be enabled by secure attachment, but subsequent relationships, secure or complex, influence mentalizing in turn, affecting the capacity to establish trusting relationships with teachers, which enable learning and sustain change.¹⁶

Looked at in this way, mentalizing theory is an essentially or even quintessentially systemic construct that enables clinicians to acknowledge and explore the web of influences on an individual's ability to understand and interpret mental states, moving beyond the individual to encompass the broader networks and systems they are embedded within. Rather than isolating individual parts, such as ‘cognitive or emotional empathy’, it emphasises the interconnectedness and interdependencies within the mentalizing system, be these at biological, social or organisational levels. By viewing problems and situations through a systems lens, we can better discern patterns, relationships and structures underlying mentalizing processes that ultimately drive behaviours and outcomes.

The benefit of such a broad conceptualisation is that it enables more strategic interventions focused on mentalizing, which potentially fosters resilience and promotes sustainable changes in those we intend to support by accounting for the broader context and ecological ripple effects of any given action. In other words, the recommendations the paper makes in terms of targeted prevention, enhanced supervision, trauma-informed education and so on have implications beyond growing the capacity of the individual trainee to cope with what is a complex and exceptionally challenging set of demands to simultaneously learn and perform difficult clinical duties and entails modifying the system of training, so that it changes itself to become more mindful of the psychological impact of the requirements we place on young psychiatrists and other physicians. There is substantial variation across European trainee psychiatrists in terms of burnout with the prevalence of severe cases ranging between 15% and 50%.¹⁷ Such disparities likely mirror the differences in the systems of support available to them.

At systems level, what this paper calls for is enhancing the capacity of training systems to mentalize trainee psychiatrists, to see juniors as they experience the world. At the same time, it suggests creating a system where we increasingly see each other as thinking, feeling and desiring people, not just performing, delivering and reacting doctors. By adopting a systems perspective, we extend our understanding beyond mere individual cognition to the dynamic interactions that occur between individuals in various relationships. These relationships can be clinical, educational or personal, involving families, peer groups and other social networks, all of which possess the potential to bolster mentalizing capabilities.^{18, 19} The enduring effects of adversity on mentalizing may be attributed to ‘social thinning’:²⁰ the diminishing of the social environment of the traumatised individual. This reduction in social interaction can adversely affect social learning, primarily due to the erosion of epistemic trust.¹⁶ Epistemic trust refers to the willingness to consider new information as trustworthy, relevant and applicable to oneself, and is fundamental for learning from others. When an individual experiences trauma, their capacity to trust and engage in meaningful social interactions can be significantly impaired. This disruption in social learning can hinder the development professional knowledge as well as the exercise of mentalizing. Recognising and addressing these challenges may be crucial for supporting individuals who have experienced adversity, particularly in settings like psychiatric training, where understanding mental states is integral to both personal well-being and professional competence.

Does a mentalizing perspective help in suggesting changes to training in psychiatry? Our understandings and responses continually influence and are influenced by others' reactions creating feedback loops in dynamic systems.²¹ In particular, in our approach to clinical supervision, we ask clinicians to focus on the potential of mentalizing to yield misinterpretations of intentions behind actions and how such misinterpretations can drive responses that triggers further misunderstandings, creating a feedback loop of miscommunication. Training that incorporates mentalizing can help psychiatrists develop skills that are crucial for their role, such as empathy, reflection and a better understanding of the patient's perspective. It also encourages a culture of openness and reflective practice, which is essential for personal and professional growth. In summary, a mentalizing perspective can be a powerful tool in reshaping psychiatric training to foster more empathetic, reflective and effective clinicians.

The concept of mentalizing holds the potential to transform environments like schools and workplaces, which play a crucial role in shaping behaviours.²² Recognising how social systems can either facilitate or impede mentalizing opens a significant opportunity for developing educational and institutional frameworks that are conducive to mentalizing, thereby helping to prevent work-related burnout. Acknowledging that an individual's capacity to mentalize is influenced by various systems implies that effective interventions may need to be multi-faceted. In the context of training, particularly for psychiatric trainees, it becomes imperative to simultaneously address multiple systems if mentalizing is to be sustainably enhanced. This approach goes beyond just individual counselling. It encompasses educational modifications, as well as broader institutional awareness initiatives. By doing so, training programmes can create an environment that not only enhances the mentalizing abilities of trainees but also fosters a culture of understanding, empathy and effective communication in the educational corridors and institutional frameworks, where individuals learn and mature, further mould professional skills. Acknowledging that mentalizing ability does not exist in a vacuum means that to truly foster it, our interventions might need to weave through multiple facets of an individual's life. Recognising the role universities or hospitals play in fostering or inhibiting mentalizing can be instrumental.

Yet, our grasp on mental states is not just confined to our immediate environment. The international variations in burnout rates raise questions about cultural differences in resilience and mentalizing.²³ The wider cultural and societal contexts play also key roles. How psychiatry is regarded in a society will have an impact. Every culture has its unique lexicon of expressing and interpreting emotions, shaped by norms, values and shared beliefs. Societal conventions, in particular, can either act as catalysts or impediments to our mentalizing abilities. Understanding these cultural dimensions is crucial for developing effective strategies and interventions that are sensitive to the varied backgrounds and experiences of trainee psychiatrists, ultimately leading to better mental health outcomes and more effective training programmes.

This report is independent research supported by the National Institute for Health and Care Research ARC North Thames. The views expressed in this publication are those of the author(s) and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care.

The author declares no conflict of interest.